Eating disorders

Question 1

What is bulimia nervosa?

Answer 1

An eating disorder in which there are periods of binge eating followed by compensatory weight loss behaviours ie. induced vomiting, fasting, intense exercise, medication abuse (laxatives, thyroxine etc)

Question 2

Feature of a patient with bulimia nervosa?

Answer 2

Obsessed with body shape and weight
Weight is overly important on self evaluation
Feel like they can’t control their eating
Post-binge techniques to compensate for binge (induced vomiting, fasting, intense exercise, medication abuse (laxatives, thyroxine etc))

Question 3

More common in which sex?

Answer 3

Females - 10:1

2% lifetime prevalence in females

Question 4

Physical symptoms of bulimia nervosa

Answer 4

Bloating/fullness
Lethargy
Heartburn/reflux
Abdominal pain
Sore throat, dental problems (from vomiting)

Question 5

Severe signs of bulimia nervosa

Answer 5

• Swollen salivary (parotid) glands
• If diuretic/laxative abuse - oedema
• If inducing vomiting - Russel’s sign (calluses form on back of hands from hand scraping against teeth when trying to induce vomiting)
• Erosion of dental enamel due to repeated vomiting

Question 6

What you’re looking for on examination (as well as the severe signs) - for bulimia nervosa

Answer 6

Dehydration
Arrhythmias (from hypokalaemia)
BMI - take weight and height
Blood pressure

Investigations - U&Es - K, renal function

Question 7

Management of bulimia nervosa

Answer 7

First line - self help program for BN (family therapy if under 18)
second line - CBT-ED - eating disorder focused CBT

Refer to specialist eating disorder service
Manage suicide risk
Manage low potassium
Check fluids/U&Es regularly
Dentist visits

Question 8

Complications of bulimia nervosa

Answer 8

Haematemesis
Hypokalaemia
dental erosions
anorexia nervosa

Question 9

Anorexia nervosa - overview

Answer 9

Maintain a low body weight, obsessed with being thin or not being fat. They believe that they are fat already so dont want to put more weight on.

Low body weight
rapid weight loss
weight loss measures (extreme dieting)
psychological features (distorted body image)
fear of gaining weight

Question 10

Clinical features of anorexia nervosa

Answer 10

Low BMI
Restrictive dieting
Distorted view of body, denial of a problem
Over exercise etc to lose more weight
Amenorrhoea 3+ months
GI symptoms - constipation, bloated after food, dysphagia, abdominal pain
Fatigue, fainting, dizzy, cold intolerance
Muscle loss (inc. diaphragm and HEART (HR,BP etc!)
Bone marrow bad, less WBC, RBC, platelets
Brittle hair on head, soft on skin (lanugo)

Question 11

Examination findings in anorexia nervosa

Answer 11

U&Es, ECG, DEXA scan

low BMI (below 13 - high risk)
Low HR (under 40 - high risk)
Low temperature (under 35 risk)
Hypotension (under 90/70, postural drop >10)
Peripheral oedema (heart weak and low protein)
Proximal muscle weakness (squat test (not using arms))
Osteoporosis on DEXA scan

Question 12

Management of anorexia nervosa

Answer 12

In under 18s - AN-FT - anoroxia nervosa focused family therapy

ED-CBT(Individual eating-disorder-focused cognitive behavioural therapy)

[Also Maudsley Anorexia Nervosa Treatment for Adults (MANTRA and Specialist supportive clinical management (SSCM)]

Question 13

Bulimia vs anorexia - if they are purging and under weight what are they?

Answer 13

Anorexia. These patients can still eat lots and purge like bulimia but they are underweight. Bulimic patients are normal or overweight

Question 14

Refeeding syndrome - what happens if starving people eat loads

Answer 14

Insulin secretion causes cells to take in already low levels of K, Mg, PO4 - risk of arrhythmias

Question 15

Psychological symptoms of anorexia nervosa

Answer 15

Low self esteem
Lonely 
Sensitive to criticism 
Need approval 
Over react
Perfectionism

Question 16

Binge eating disorder - overview

Answer 16

regularly eating large portions of food all at once until you feel uncomfortably full, and then often upset or guilty.
eat even when full, not hungry, and eating fast
feel out of control during these episodes

treatment - self help + CBT

Question 17

Other specified feeding or eating disorder (OSFED) - overview

Answer 17

These are eating disorders that don’t tick all the boxes needed to make a diagnosis such as anorexia, bulimia or binge eating disorder.

Question 18

Starvation - what happens metabolically

Answer 18

Normally body uses glucose as energy. Glucagon releases this from the glycogen stores which replenish after meals.
Starvation response begins when glycogen stores are depleted
Fatty acids become main energy source (brain continues with glucose) - first 2-3 days
Next ketone bodies (from fatty acids) are used for energy by brain (2-3days)
Next proteins are broken down into glucose etc - these come mostly from muscle in the body - hence the muscle wasting seen in starvation

ketoacidosis can occur - metabolic acidosis

so glucose should be given IV slowly…

Question 19

Why does brain suffer if starving? Why do you get cognitive impairment?

Answer 19

Only 75% of brains energy requirement can be provided via ketone bodies so there is a deficit and impairment

Question 20

What is Münchhausen’s Syndrome

Answer 20

• Simulated illness: either physical or psychiatric. (can contaminate samples to look pathological)
• Pathological lying (pseudologia fantastica).
• Wandering from place to place (peregrination): the patient typically presents to numerous different hospitals, using different names.

May self inflict disease - ie eating contaminated food to induce food poisoning